Functional Abilities Form for Planning Early and Safe Return to Work (2647A) – WSIB in Ontario

The Functional Abilities Form for Planning Early and Safe Return to Work (Form 2647A) is designed to help health professionals provide detailed information about a patient’s functional abilities and work restrictions. This information assists employers in planning a safe and timely return to work for their employees. Health professionals are required to complete this form upon request by an employer or worker and submit it promptly to ensure effective return-to-work planning. The form 2647A includes sections for the worker’s and employer’s details, health professional’s assessment, and specific abilities or restrictions. It emphasizes confidentiality, especially regarding billing information.

Section A: Worker and Employer Information

Worker Information

1. • Fill in the worker’s first name, last name, and telephone number.
   • Provide the worker’s complete address, including city/town, province, and postal code.
   • Include the worker’s date of birth and the date of the accident or awareness of illness.

Employer Information

1. • Enter the employer’s name, full address, including city/town, province, and postal code.
   • Provide the employer’s telephone and fax numbers.
   • Indicate the type of job the worker was performing at the time of the accident (attach a job description if available).
   • Note whether the worker and employer have discussed the return-to-work plan, and if not, specify when it will be discussed.
   • Provide the name and position of the employer contact.

Authorization

1. • The worker must sign and date the form to authorize the release of their functional abilities information to the employer and the WSIB.

Section B: Health Professional’s Billing Information

Health Professional Details

1. • Select the appropriate designation (Chiropractor, Physician, Physiotherapist, Registered Nurse, etc.).
   • Provide the WSIB Provider ID, and if not registered, follow the instructions to register.
   • Fill in the health professional’s name, invoice number, and address.
   • Include the HST registration number and HST amount billed, if applicable.
   • The health professional must sign and date this section.

Section C: Worker’s Functional Abilities and Restrictions

Assessment Details

1. • Fill in the date of assessment.
   • Indicate whether the patient can return to work with no restrictions, with restrictions, or is unable to return to work at this time.

Abilities and Restrictions

1. • Specify the worker’s abilities in terms of walking, standing, sitting, lifting (from floor to waist and waist to shoulder), stair climbing, ladder climbing, and travel to work.
   • Detail any restrictions, such as limited use of hands, environmental or chemical exposure, and limitations on pushing/pulling or operating equipment.
   • Note any potential side effects from medications without specifying the medication names.
   • Add any additional comments on abilities or restrictions.

Duration and Recommendations

1. • Indicate how long the assessed abilities/restrictions will apply.
   • Confirm if the return-to-work plan has been discussed with the patient.
   • Provide recommendations for work hours and start date.

Section D: Next Steps

Next Appointment

1. • Recommend a date for the next appointment to review abilities and/or restrictions.

Form Distribution

1. • Ensure the completed form is provided to both the worker and employer.

Submission Instructions

• Mail: Send the completed form to Workplace Safety and Insurance Board, 200 Front Street West, Toronto, ON M5V 3J1.
• Fax: Fax the completed form to 416-344-4684 or 1-888-313-7373.

Additional Tips

• Use black ink for all entries.
• Ensure all relevant sections are completed fully and accurately.
• Do not include billing information on the copies provided to the worker or employer.

By following these instructions, you can ensure that the Functional Abilities Form is filled out correctly, facilitating a smooth and safe return to work process for the worker.